Provider Demographics
NPI:1033193800
Name:MERLIN, MARK LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LOUIS
Last Name:MERLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 116470
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6470
Mailing Address - Country:US
Mailing Address - Phone:770-682-2080
Mailing Address - Fax:678-579-9398
Practice Address - Street 1:2349 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3143
Practice Address - Country:US
Practice Address - Phone:404-320-1550
Practice Address - Fax:404-728-1081
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039178174400000X
GA391782085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA165022770CMedicaid
GAG37708Medicare UPIN
GA165022770CMedicaid
GAG37708Medicare UPIN